8 Abstract 1.1 COURSE OF EVENTS In relation to blasting operations conducted as a part of road construction project Fv. 78 Arm Ømmervatn, the mobile unit for on-site production of bulk explosives owned by Maxam, MEMU F-114, arrived at Drevja on 17th December 2013 at approximately 12:00, after a 160 km transfer from the depot at Brønnøy Kalk, Norway. F-114 was carrying precursors for production of bulk explosives, and the main components being ANPP and ANE. The production was initiated and at approximately 13:00, a fire was identified on the right side at the front of the vehicle. After ending an unsuccessful attempt to extinguish the fire, the construction site and residential homes in the immediate area were evacuated. The police and the fire brigade were alerted and arrived at the site. The duration of the fire was approximately 2.5 hours. It is likely that after about 1.5 hours, the fire had spread to the ground beneath and in front of the vehicle. After about 2 hours, the fire had enclosed the entire vehicle and it is likely that the cab had burned out. The final 5 minutes, after about 2 hours and 21 minutes up to the moment of explosion, the fire intensified significantly. There were considerable material damages to the surrounding environment after the explosion. A residential home burned to the ground, several buildings had structural damages and broken windows, and construction equipment in the area was damaged. No persons were injured. 1.2 APPROVALS, CERTIFICATES OF CONFORMITY AND AUTHORISATION FOR MANUFACTURE The Norwegian Public Roads Administration (NPRA), Risløkka Traffic Services Office, approved F-114 after an initial inspection in accordance with ADR on 17th June After this, the vehicle was subject to periodic inspections. The last inspection took place on 12th February The tanks with associated equipment were ADR approved by DNV on 11th May The MEMU approval and the authorisation for manufacture under the Regulations on Explosives for F-114 were granted synchronously by DSB, in the decision dated 8th June The authorisation is valid for products in the Riomex series. According to ADR, UN 3375 must be approved by the competent authority. Carriage of UN 3375 in tanks is further subject to a special requirement on suitability of the substance for carriage in tanks, and must be tested with a method approved by the competent authority. Maxam has submitted documentation from BAM concerning the approval of UN 3375, and the suitability of the product for carriage in tanks. The traceability in the documents is not satisfactory. The provisions of the Regulations on Explosives define specific requirements for the conformity assessment and the certificate of conformity including accompanying documentation for explosives. BAM has certified that a prototype of Riomex SC 7000 meets the basic safety requirements of Directive 93/15 EEC, which is implemented through the Regulations on Explosives. 6 Explosion Accident during Mobile Production of Bulk Explosives / DSB REPORT

9 Abstract 1.3 MOBILE PRODUCTION OF EXPLOSIVES ON MEMU F-114 The explosive Riomex SC 7000 manufactured by F-114 is a mixture comprised by several components. Riomex SC 7000 is prepared through a process, of which ammonium nitrate porous prills (ANPP) and diesel is added to emulsion (ANE), before the mixture is sensitized. This type of bulk explosive is intended for use above ground only. Riomex SC 7000 is sensitized through chemical gassing, and the formation of gas is catalysed by the addition of acid at the outlet of the product pump. The capacity of F-114 was about 13 tonnes. 1.4 ANALYSIS OF THE COURSE OF EVENTS Throughout the working process, the project committee continually assessed which information was possible to obtain in order to analyse the incident in Drevja. Three surveys were conducted; photo material from the incident was collected, the persons involved were interviewed and key documentation from Maxam was obtained. Based on statements from witnesses and photos, it is most likely that the fire started in the electrical system on the lower right side of the chassis. A correlation between faults in the electrical system and the fire is considered likely by the committee. During the inspection conducted immediately after the accident, it was observed that the MEMU was highly fragmented, no clear impact crater had formed, cartridged explosives were found intact close to the blast area and immediate surroundings were apparently little affected by the pressure wave. The project committee suggests that the given geological conditions on the site may be the main explanation as to why no impact crater was formed. Given a 2.5 hours duration of the fire, involving a significant fire impact and estimated temperatures of more than 1200 C, the project committee considers it most likely that the ANPP had melted, and that both ANPP and ANE had started to decompose. It cannot be excluded that the detonation characteristics of the chemicals to a large extent may have changed, as high temperatures and possible contamination by organic material are among the factors which increase sensitivity. The project committee does not consider the findings of molten aluminium fragments as sufficient proof on its own that the tanks melted, but it does indicate a weakening of the aluminium that may have caused the tanks to burst. FFI's (Norwegian Defence Research Establishment) simulation of the engine block s trajectory indicates that a considerable force has emerged from the ground, very close to or from partially below the engine. Hence the committee deems it most probable that at least one tank had bursted, causing the chemicals to leak and drain into the ground. The committee is further of the opinion that the basis for concluding how the materials were distributed and spread on the ground, is insufficient. The intention of using aluminium tanks has been to reduce the likelihood of a fire causing an explosion. This incident demonstrates that the use of aluminium tanks as a means to prevent explosion in a MEMU on fire, is not sufficient. Explosive yield calculations have been performed based on the extent of damage to buildings, the trajectory of the engine block and registered vibrations in the ground. It is not possible to conclude accurately on the size of the detonated charge, but the project committee estimates that an amount corresponding to kg TNT is probable. The committee has further judged the basis for estimating the TNT equivalent amount of ANPP and ANE involved in the blast to be insufficient, as it will provide uncertain and not constructive numbers. Findings of vital parts substantiates that the explosion was not initiated in the pump, and in neither the vertical nor the horizontal auger. Beyond this, it is very difficult to determine what initiated the explosion. DSB REPORT / Explosion Accident during Mobile Production of Bulk Explosives 7

10 Abstract FFI s analysis of the extent, size and dispersion of the aluminium fragments substantiates a detonation in both aluminium tanks. At the same time, the committee believes it is relatively certain that the original amounts of both ANPP and ANE present before the fire broke out, were not involved in an ideal detonation. This would represent a much larger explosive potential than what was observed in Drevja. Despite considerable amounts of information gathered and analyses performed by, it is still difficult to outline a complete course of events. Hypotheses are introduced to illustrate possible course of events and the needs for specific knowledge. The hypotheses include the possibilities of the explosion occurring in the ANPP tank or the ANE tank and on or above the ground. 1.5 PREVENTIVE MEASURES After an accident like the one in Drevja, a thorough evaluation to assess whether safety levels are good enough during mobile production of explosives, is a matter of course. The overall objective for the government and the industry is to minimise the risk of similar incidents happening again. Measures which shall improve safety of mobile production of explosives even further must be considered in a holistic safety perspective, and with the recognition that handling of explosives and other dangerous substances will always be associated with risk. The project committee generally assesses the risks related to mobile manufacture of explosives to be acceptable, despite the accident in Drevja. However, we believe risks are not assessed appropriately for a fire scenario. There may also be other scenarios or conditions present which change the risk situation. In the process of assessing which measures need investigation, the committee has worked towards the objective of looking holistically at risks related to mobile manufacture of explosives. We recommend measures that highlight the possibilities for further risk reduction under normal conditions as well as in extraordinary situations. The project committee in DSB proposes a package of measures comprised by the following: Changed procedures for applications for manufacture. Follow up on non-conformances identified through document audits. Assess the need for regulatory changes. Evaluate possible fire prevention and firefighting actions. Assess the need for a comprehensive assessment of the risks related to mobile production of explosives. Acquire specific knowledge. Non-conformances identified through work conducted by the project committee will be followed up with Maxam as they would subsequent to a regular audit. Non-conformances identified are not considered to have had direct consequences for the incident. DSB will during 2015 revise the Regulations on Explosives, and initiate and maintain the progression of the work involving the proposed measures. 8 Explosion Accident during Mobile Production of Bulk Explosives / DSB REPORT

12 Introduction 2.1 AUTHORISATION AND ORGANISATION After the explosion in Drevja, a project committee was assembled in DSB and given the following commission: "The project committee has been commissioned to make an independent assessment of the accident that took place in Drevja on 17th December 2013, to seek to clarify the cause of the fire in the vehicle, the reason the fire evolved and why the fire led to an explosion. The project committee shall propose any necessary measures to prevent similar incidents, as well as identifying any violations of the regulations enforced by DSB. The project committee shall involve the industry and identified measures must have strong ties to a joint industry. DSB has already informed the industry that there may be a need for conducting full-scale tests. The committee shall make recommendations as to whether tests are necessary, and if that is the case, which tests." The project committees specific objectives were to: Provide a detailed description of the course of events. Provide a description of the scene of the accident and the discoveries made there. Assess the blast effects. Create a probability assessment of potential causes. Seek to provide a conclusion. Propose appropriate measures in order to reduce the risk of similar incidents. Provide input to the further developments of the regulations. Arrange a theme day with the suppliers of explosive materials. Assess the need for full-scale tests. Identify any violations of the regulations. The project owner was the Head of Department Siri Hagehaugen from the Unit of Explosive Safety (EKS), and project managers were Gry Haugsnes and Axel Proet-Høst. Project committee members were Olav Jacobsen, Jan Øistein Kristoffersen, Bente Tornsjø, Maria Elisabeth Due-Hansen and Odd Arne Grøvo. Project owner Siri Hagehaugen reported further to Torill Tandberg, the Director of the Department for Business, Products and Hazardous Substances (NPF). The project committee was authorised to recruit external expertise. Important collaborating partners have been the Defence Research Establishment (FFI), Norwegian Geotechnical Institute (NGI), the Norwegian Public Roads Administration (NPRA) and the Norwegian Defence Estates Agency (NDEA). A dialogue meeting with suppliers of explosive materials has also been conducted during the process. 2.2 BACKGROUND MEMU is an abbreviation for Mobile Explosives Manufacturing Unit. The definition of a MEMU in ADR is as follows: "A unit or a vehicle mounted with a unit, for manufacturing and charging explosives from dangerous goods that are not explosives. The unit consists of various tanks and bulk containers and process equipment as well as pumps and related equipment. The MEMU may have special compartments for packaged explosives." As of today, approximately 80% of all explosives used in Norway are bulk explosives and an increase is expected in upcoming years also for smaller blast operations. Worldwide, there are many different ways to produce and charge bulk explosives. MEMUs are used for blasting operations both above ground and underground. Primarily units blending emulsions and gassing agents are being used underground. New and better charging units are continually being developed. Today MEMUs are used above ground for both larger and smaller blasting operations. A MEMU intended for larger blasting operations typically has a capacity of 7-14 tonnes and a MEMU 10 Explosion Accident during Mobile Production of Bulk Explosives / DSB REPORT

13 Introduction intended for smaller operations has a capacity of 1-3 tonnes. Previously there have been no major accidents involving a MEMU, but ammonium nitrate and ammonium nitrate-fuel oil have been involved in a number of accidents. DSB decided during spring 2013 to investigate the governing of explosives including the on-site production of explosives using mobile manufacturing units. An internal working group was established to obtain necessary information and make recommendations concerning the future regulations and governing of the field. External consultancy support was employed to investigate the following: 1. A description of the technical and practical developments of bulk explosives and handling onsite, and an analysis of future development. 2. A description of the on-site production process of emulsion and bulk explosives. 3. A description of good practice in the industry. The internal working group should have delivered the recommendations by February 2014, but due to the review of the accident in Drevja, the deadline was postponed pending the report of the Drevja accident. 2.3 RELEVANT REGULATIONS Act No. 20 of 14 June 2001 relating to the prevention of fire, explosion and accidents involving hazardous substances and the fire service (The Fire and Explosion Protection Act) is the act that maintains safety and the handling of explosive precursors and the manufacture of explosives. The law is elaborated through a number of key regulations. In relation to the Drevja accident, the following regulations issued pursuant to the Fire and Explosion Protection Act, the Working Environment Act and the Product Control Act respectively, are relevant: Regulations No. 384 of 1 April 2009 concerning the inland carriage of dangerous goods (the Inland Transport Regulations) Regulations No. 544 of 20 May 2009 concerning machinery (the Machinery Regulations) Regulations No of 6 December 2011 concerning performance of work Regulations No. 602 of 8 June 2009 relating to the handling of flammable, reactive and pressurised substances including requisite equipment and installations (the Regulations on the handling of Hazardous Substances). Regulations No. 922 of 26 June 2002 concerning the handling of explosive substances (the Regulations on Explosives). Regulations No of 6 December 1996 relating to systematic health, environment and safety activities in enterprises (the Internal Control Regulations). DSB REPORT / Explosion Accident during Mobile Production of Bulk Explosives 11

16 Course of Events The description of the course of events is based on reports and logs from the fire department, questioning performed by the police, interviews performed by DSB and on photos taken by the contractor, fire department, police and Maxam Norge AS. The Norwegian Public Roads Administration Region Nord was the owner of the road construction project Fv.78 Arm Ømmervatn-P1304. Johs. J. Syltern AS was the main contractor in this project while RockNor AS was the blast contractor. The project was expected to finish in October Maxam Norge AS (Maxam) was responsible for the delivery of bulk explosives. Figure 1. Where the operator stood in relation to the fire. In connection with the project Fv.78, a quarry was constructed. On December 17th 2013, MEMU F-114, owned by Maxam, arrived at approximately 12:00 to charge blast area number 50. F-114 arrived after driving 160 km from Maxams' storehouse at Brønnøy Kalk. After its arrival, the Maxam operator prepared F-114 for production/pumping. The MEMU was placed in a slope with its rear end pointing uphill towards the blast area, thus situating its ANPP tank at a lower point (Figure 2). The production commenced at approximately 12:00. When initiated, the production starts first followed by product pumping. At this time the operator of the pump was situated by the cabinet on the left rear side of the truck, where the operator console for the production unit was placed (Figure 1). During production/pumping, the engine was running and the lights were turned on. Two RockNor employees were situated at the rear end of the vehicle close to the blast area, when the fire was discovered. At approximately 13:00 the power supply shut down. The operator heard the characteristic sound of (compressed) air leakage whereafter the engine shut down immediately. The operator walked up to the cab and discovered white/grey smoke coming from the right front side of the vehicle. Subsequently, the operator went over to the passenger side and turned off the main power supply. When the operator opened the passenger door, the cab was filled with black smoke and visible flames were seen both on the in- and outside of the vehicle. The flames blazed towards the operator from the dashboard from the floor and up. Figure 2. Picture of where the fire started. The three people on site tried to extinguish the fire with dry powder fire extinguishers from F-114 and from other vehicles in the area. At the beginning, the extinguishers were directed towards the fuse box on the lower right side of the dashboard. Later on, they were directed from the outside onto the right side of the cab. The flames reappeared every time and finally all extinguishers were empty. Thus, it was decided to discontinue the extinguishing and rather commence an evacuation. The operator manually set off the automatic fire extinguisher in the engine compartment before he left the vehicle. At approximately 13:11, the operator called 110 (the fire brigade). Shortly after this, all the people working in the area (40 persons) were evacuated approximately 500 meters. The road was also closed in both directions. In addition, all residents in the range of 500 meters were identified and evacuated. 14 Explosion Accident during Mobile Production of Bulk Explosives / DSB REPORT

17 Course of Events Eastern Barrier Explosion Site Western Barrier Figure 3. Map displaying the position of the MEMU and the eastern and the western barrier Scale 1:6500 Statens vegvesen During the evacuation, there was a continuous dialogue between the Maxam operator and the police concerning the chemicals on board of the truck. The police was also in dialogue with DSB concerning evacuation zones. The police executive arrived at approximately 13:40 and the fire brigade arrived at approximately 13:50. At 14:21 the evacuation zone was expanded to meters, however, to the best of our knowledge it seems that the eastern barrier ended on meters while the western barrier was placed at approximately 500 meters. The eastern barrier was moved during the fire due to smoke. The map (Figure 3) displays the position of MEMU F-114 and the eastern and western barrier. The police executive, employees at the NPRA and the Maxam operator were situated at the eastern barrier, while employees from Johs. J. Syltern, the police, NPRA and the fire brigade chief was located at the western barrier. Both fire and production of smoke varied in intensity. Briefly before the explosion, the fire intensity increased considerably. After approximately 2.5 hours on fire, F-114 exploded at 15:24. The material damages in the area were of great extent. A private house burned to the ground while several other buildings suffered from structural damages and broken windows. Construction machines in the area were also damaged. There were no casualties. The explosion was recorded on a mobile phone camera approximately 3 km from the site. After the explosion, the area was closed until the next day. In the afternoon on December 18th, representatives from Maxam and the contractor of the project entered the area to collect cartridged explosives and initiators remaining on the surface of the area. The ones lying closest to the truck were affected by the fire to some extent. The amount of collected explosives was the same as the initial amount before the fire was discovered. On December 20th, blast number 50 was detonated. DSB REPORT / Explosion Accident during Mobile Production of Bulk Explosives 15

20 Certain Relevant Requirements for MEMUs and On-Site Production of Bulk Explosives 4.1 REQUIREMENTS FOR RISK ASSESSMENT AND EVALUATION OF DOCUMENTATION PRESENTED The Fire and Explosion Protection Act 19 and 20 are relevant provisions for any business which handle hazardous substances. The company shall ensure that the level of safety is good enough and safety considerations should be integrated in all business phases including planning, design, establishment, operation and decommissioning. Risks should be reduced to a level that can be reasonably achieved (the ALARP principle). There will always be a residual risk associated with the handling of explosive substances which normally has to be accepted in society. Such an acceptable level can be determined in several ways, for example as a quantified level of likelihood of a given type of accident and its consequences, or as a qualitative description. What can be reasonably achieved expresses a principle where the costs associated with the reduction of risk must be compared with the safety benefits that can be achieved. The provision of the Regulations on Explosives 2-2 on requirements for businesses stipulates that the business should identify hazards and problems that can arise when handling explosive substances, and implement compensatory measures. This provision has a content corresponding to the Regulations on the Handling of Hazardous Substances of the Internal Control Regulations states that a business shall identify hazards and problems, and based on this assess risks as well as establishing accompanying plans and measures to reduce the risk factors. It is required that must shall be documented in writing. The requirement to document risk assessments within the business, and that this should result in plans and measures to reduce the risk to an acceptable level, is therefore rooted in several regulations. Understanding of risk is something a person, industry or business may have, partially have or not have. The prerequisites for a good understanding of risk are that a risk assessment has been conducted, that the risks are recognised and endeavoured minimised, and that a plan exists for managing the remaining risk. Achieving a good understanding of risk within an organisation requires interdisciplinary processes and good training/rehearsals. A risk assessment should include a system description (what will be analysed), hazard identification as well as consequence and probability assessments for identified hazards. For identified hazards, technical and organisational measures should be implemented in order to reduce the risk to a satisfactory level, and contingency plans should be prepared if necessary. The project committee has inquired about which risk assessments Maxam has developed of the project design and commencement using MEMUs, including a HAZOP analysis for on-site production. Associated with the fact that MEMU F-114 was involved in a collision, an explanation of how Maxam assessed whether the collision affected the risk situation was also requested. According to Maxam, a risk assessment was conducted, but this is not documented. The project committee is of the perception that risk assessments within the business are insufficiently documented. The project committee has received Maxam Europe's HAZOP for on-site production. HAZOP (Hazard and Operability) is a qualitative method suitable for identifying hazards of processes and operating terms, and can be a supplement to a risk analysis. When hazards are identified, measures shall be implemented to prevent these situations from arising. The document provides an overview of the elements to be analysed. Non-conformances and causes for non-conformances are well documented, but we question how consequences, security measures and corrective actions are described in the document and how they are implemented. Concerning the question of whether the collision affected the risk situation, it is Maxam s view that a full restoration at an authorised garage did not affect the risk situation, and Maxam s Management of Change procedure was therefore not implemented. 18 Explosion Accident during Mobile Production of Bulk Explosives / DSB REPORT

21 Certain Relevant Requirements for MEMUs and On-Site Production of Bulk Explosives The project committee is in principle of the opinion that a significant reconditioning of the electrical system on an ADR vehicle should call for a raised alertness until it is certain that the repair was satisfactorily performed. The committee has not taken a decision on what this extra alertness should entail. After the repair following the collision with the elks, a bull bar (frontal protection system) was mounted at the front of the vehicle. The bull bar restricts the access to the engine compartment. This report does not claim that the bull bar was the reason that the fire could not be extinguished. What the project committee however does question, is whether Maxam should have implemented the Management of Change procedure for mounting the bull bar. The committee assesses the risk situation of a fire in the engine compartment to have changed when the opportunities for extinguishing the fire has changed. The assembly of new equipment is a change, and any need for communication to employees regarding new risk factors, training etc. should be carefully considered. 4.2 APPROVAL OF F- 114 BY THE NPRA The Inland Transport Regulations apply to the carriage of UN 1942 ammonium nitrate, UN 3375 emulsion and other dangerous substances which are considered dangerous goods according to the UN Recommendations on the Transport of Dangerous Goods. The annexes to the European Agreement concerning the International Carriage of dangerous goods by Road (ADR), which is an integral part of the Inland Transport Regulations, did from 1st January 2009 introduce specific provisions for the transport of dangerous goods on MEMUs. This includes provisions for the construction of tanks, bulk containers and special compartments for these units in Chapter 6.12, and provisions concerning the construction of MEMUs in Part 9. The purpose of the provisions of ADR is to maintain safety during carriage of dangerous goods by road. The various technical requirements, design specifications etc. in ADR also have a positive impact on safety at the moment the production of bulk explosives is initiated, i.e. after the transport operation has ended. Hence the provisions of ADR have been considered in the report compiled by the project committee. Approvals of MEMUs are performed by NPRA according to ADR Section 9.1.2, which issue certificates of approval in accordance with ADR Section In order to have the certificate of approval issued, the vehicle's compliance shall be verified through an initial inspection. Subsequently, an annual technical inspection is required in order to extend the validation of the certificate of approval. This annual inspection shall cover the relevant provisions of ADR as well as the general technical requirements for vehicles. Only the part of the annual inspection concerning ADR must be conducted by NPRA. The remaining part of the examination can be performed at a garage approved by NPRA for such inspections. MEMUs must fulfill the requirements for relevant base vehicles as specified in Chapter 9.2. This include requirements for wiring, battery master switch, batteries, permanently energised circuits, electrical installation at rear of cab, braking equipment, antilock braking system, endurance braking system, fuel tanks, engine, exhaust system, prevention of fire risks, combustion heaters, speed limitation device and coupling device of trailers. Chapter 9.8 applies additional requirements concerning complete or completed MEMUs. Listed here are the requirements for tanks and bulk containers, earthing systems, stability and protection against rear impact. Included in this chapter is also the requirement for an automatic fire extinguisher system for the engine compartment. Provisions on firefighting materials are given in ADR Section The provisions specify the quantities, types and locations of hand extinguishers to be placed on the vehicles. With regards to the initial inspection under ADR, F-114 was approved on the third attempt on 17th June 2010 by NPRA, Risløkka Traffic Services Office. All non-conformance remarks noted under the first inspection had then been rectified. The vehicle had DSB REPORT / Explosion Accident during Mobile Production of Bulk Explosives 19

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